Progress    and     Problems 
in    Preventive    Medicine 


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Ether  Day  Address 
1913 


Progress    and    Problems 
in    Preventive   Medicine 


BY 

MILTON  J.  ROSENAU,  M,D. 

Professor  of  Prev €71110; e  Medicine 
and  Hygiene 


Ether  Day  Address 
1913 


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CAT.  FOR 
aiBUCHEALm 

m-  Li 
'    GIFT 


th*  Jamaita  Printing  Comfnj 
Jamaica  Plain,  "Boston,  Mass. 


PUBLIC 
KE.^LTH 
UBRAKY 


PEOGRESS  AND  PROBLEMS  IN  PREVENTIVE 
MEDICINE.* 

BT    M.    J.    ROSEXAtr,    M.D.,    BOSTON, 

Professor  of  Preventive  Medicine  and  Hygiene,  Harvard  Medical  School. 

The  Massachusetts  General  Hospital  has  long  been  a 
hospital  of  hospitals,  a  teacher  of  teachers,  a  physician  to 
physicians.  It  has  a  proud  heritage  from  the  past  that  is 
also  a  heavy  responsibility  for  the  present.  Its  ideals  have 
extended  beyond  the  waUs  of  the  institution,  for  in  addi- 
tion to  administering  to  the  sick,  it  has  taken  an  active 
part  in  the  history  of  American  medicine,  and  it  has  been 
a  model  that  has  been  copied  far  and  wide.  Its  many 
achievements  on  the  side  of  science,  its  humanity  as  ex- 
pressed in  its  social  service  work,  and  its  long  list  of 
notable  sons  have  placed  it  in  the  forefront  of  Hotels  Dieu. 

We  are  here  to  celebrate  the  birthday  of  the  chief  among 
these  achievements — the  first  public  demonstration  of  sur- 
gical anesthesia.  Three  score  and  seven  years  ago  John 
Collins  Warren  operated  upon  Gilbert  Abbott  under  the 
deep  sleep  of  ether  administered  by  William  Morton.  We 
are  again  met  to  recall  the  deeds  and  the  men  conspicuously 
associated  with  the  Massachusetts  General  Hospital;  and 
to  dedicate  ourselves  to  the  task  of  adding  further  drops 
of  knowledge  to  the  unceasing  stream  of  blessings  which 
continue  to  flow  as  a  result  of  the  event  we  celebrate  anew 
today. 

These  blessings  have  been  rich  and  varied,  for  they  not 
alone  made  modern  surgical  practice  possible,  but  they 
opened  up  fields  of  experimental  biology  in  hitherto  un- 
suspected and  rewardful  directions.  It  was  about  the  time 
that  this  precious  gift  was  given  to  suffering  humanity 
that  Darwin  helped  us  throw  away  the  crutches  of  tra- 
ditional authority  on  which  we  limped,  that  Huxley  clearly 


*  Address  delivered  at  the  Massachusetts  General  Hospital  on  Sixty-seventh  Anni- 
versary of  Ether  Day,  Oct.  16,  1913. 

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JW863428 


defined  man's  place  in  nature,  and  Pasteur  unraveled  the 
secrets  of  fermentation  and  infection.  These  important 
conceptions  and  discoveries  marked  the  opening  of  an  era 
unparalleled  in  the  history  of  the  world  for  steady  and 
substantial  progress  in  every  branch  of  human  endeavor. 

Each  generation  retells  the  story  of  past  achievements  in 
its  own  way.  The  use  of  ether  for  the  relief  of  pain  has 
become  one  of  those  twice  told  tales  which  it  is  a  pleasure 
to  recall  and  an  honor  to  relate.  The  story  itself,  however, 
full  as  it  is  of  human  interest  and  dramatic  elements,  will 
not  here  be  repeated,  for  it  seems  more  to  the  purpose  to 
consider  some  of  the  progress  which  in  no  small  part  was 
made  possible  by  the  introduction  of  the  experimental 
method  as  exemplified  in  the  discovery  of  ether  and  its  ap- 
plication as  an  anesthetic. 

A    CONSTRUCTIVE    PROGRAM. 

Formerly  hygienic  and  sanitary  measures  were  based 
almost  solely  upon  a  negative  program.  This  was  neces- 
sarily so  because  we  had  to  await  the  exact  observations  of 
Pasteur  before  the  sanitary  sciences  could  be  placed  upon  a 
sound  basis  of  fact.  The  old  books  of  hygiene  were  full  of 
fads  and  fancies.  By  the  old  books  I  do  not  mean  ancient 
tomes,  but  the  books  which  were  regarded  as  authority  when 
I  was  a  medical  student.  The  whole  sanitary  system  was 
then  a  vague  or  confused  jumble  and  an  uncertain  guide. 
The  system  was  an  assemblage  of  sanitary  dont's.  We 
were  told  what  not  to  do,  in  order  to  avoid  infection,  or  to 
improve  our  bodily  vigor.  When  the  sanitarian  of  yester- 
day did  depart  from  this  negative  program  and  ventured  to 
give  counsel  of  a  positive  character,  it  turned  out  to  be 
mostly  guesswork  and  very  often  wrong. 

When  I  was  a  boy  they  told  me  not  to  catch  cold,  but 
they  could  not  tell  me  what  to  do  in  order  not  to  catch 
eold,  and  if  they  did  it  was  mostly  poor  advice.  Thus  I 
was  taught  to  fear  the  night  air,  whereas  now  we  know 
that  the  air  by  night  is  cleaner  than  the  air  by  day  in  that 
it  contains  less  dust  and  fewer  bacteria ;  our  common  sense 
confirms  the  observation  that  the  night  air  in  itself  contains 

4 


no  injurious  qualities.  Patients  with  tuberculosis,  and  even 
pneumonia,  are  freely  exposed  to  the  health-giving  tonic 
properties  of  the  cool  night  air. 

There  must  be  many  present  who  have  heard  about  the 
noxious  emanations  and  poisonous  miasmata  wafted  mys- 
teriously in  the  night  air,  to  fret  and  plague  us.  This 
notion  that  the  night  air  is  harmful  was  a  logical  conclu- 
sion drawn  from  the  observations  made  from  time  imme- 
morial that  malaria  stalks  by  night.  The  reason  for  this 
is  quite  clear  to  us  now  since  we  know  that  the  malarial 
mosquito,  like  the  tiger,  prowls  at  night  in  search  of  its 
quarry.  In  warm  malarious  regions  the  misinformed  folk 
close  all  the  shutters  of  the  house  very  tightly  at  nightfall 
in  order  to  keep  out  the  dreadful  malarious  miasm,  thus 
imperfectly  guarding  against  mosquitoes,  and  at  the  same 
time  favoring  the  spread  and  development  of  tuberculosis, 
which  is  especially  rife  in  the  tropical  belt.  I  have  often 
observed  that  when  one  of  these  benighted  people  sallies 
forth  into  the  night  air  he  throws  a  scarf  over  his  mouth 
and  nose  in  order  to  filter  out  the  poisonous  effluvia  from 
the  air  he  is  breathing.  At  the  same  time  I  have  seen  large 
ferocious  anopheles  mosquitoes  freely  biting  the  hand  that 
held  the  scarf  in  place. 

Furthermore,  when  I  was  a  boy  I  was  swathed  in  flan- 
nels and  partially  parboiled  in  overheated  schoolrooms; 
my  vasomotor  tone  was  so  relaxed  by  this  coddling  that  it 
could  not  respond  promptly  to  aid  my  heat-regulating 
apparatus  in  an  effective  manner.  My  nasal  mucosa  was 
soggy  and  sensitive.  Therefore,  I  was  susceptible  to  colds 
and  was  taught  to  fear  drafts.  We  now  know  that  colds 
are  caught  from  other  persons  having  colds,  just  as  diph- 
theria is  contracted  from  diphtheria.  Arctic  travelers  ex- 
posed to  all  the  rigors  ordinarily  supposed  to  produce  colds 
do  not  suffer  from  these  ailments  until  they  return  to  civi- 
lization and  become  infected  by  contact  with  their  fellow- 
men.  It  is  not  the  engineer  in  the  cab  who  catches  cold  so 
much  as  the  passengers  in  the  crowded,  stuffy,  overheated 
and  dusty  Pullmans. 

The  term  ''common  colds"  is  used  here  to  mean  the  acute 

5 


infections  of  the  mucous  membranes  of  the  upper  respira- 
tory passages.  It  does  not  include  the  many  acute  and 
chronic  congestive  inflammatory  states  due  to  reflex  me- 
chanical or  chemical  irritants  to  which  these  parts  are  di- 
rectly exposed  and  to  which  they  often  become  exquisitely 
sensitive. 

In  brief,  then,  we  are  now  able  to  tell  people  that  the 
way  to  guard  against  common  colds  is  primarily  to  avoid 
other  people  having  colds,  and  to  cultivate  hygienic  habits 
that  will  lessen  the  chances  of  the  infection  reaching  the 
mouth  and  nose ;  secondarily  to  improve  bodily  vigor  so  as 
to  increase  our  resistance  to  infection.  It  should  be  care- 
fully kept  in  mind,  however,  that  general  physical  vigor  is 
no  certain  safeguard  against  most  of  the  infections  to  which 
flesh  is  heir.  The  strong  and  robust  are  too  often  stricken 
down  in  the  prime  of  life  with  scarlet  fever,  diphtheria 
and  even  with  pneumonia,  tuberculosis  or  typhoid  fever, 
or  some  other  infection  of  our  long  repertoire. 

It  is  very  much  easier  to  tell  a  person  what  to  avoid 
than  to  teach  him  what  to  do.  We  need  constructive  les- 
sons in  hygiene  as  well  as  in  ethics.  Seven  of  the  command- 
ments of  the  decalogue  are  negative.  Almost  all  secular 
laws  are  negative.  Jurists,  learned  in  the  philosophy  of 
the  law,  tell  us  that  it  is  important  that  laws  should  be 
thus  limited  so  as  to  permit  independence  of  action.  The 
law  may  properly  state  what  a  person  may  not  do,  but  it 
should  be  careful  in  dictating  what  he  must  do.  In  hygiene 
and  sanitation,  however,  we  cannot  be  satisfied  with  this 
negative  program,  for  we  now  have  sufficient  knowledge  to 
teach  and  guide  the  people  in  the  positive  art  of  hygienic 
living.  Even  the  law,  when  applied  to  preventive  medicine, 
recognizes  this  principle.  ''The  liberty  secured  by  the 
Constitution, ' '  says  the  Supreme  Court  of  the  United  States, 
*'does  not  impart  an  absolute  right  in  each  person  to  be  at 
all  times  and  in  all  circumstances  wholly  freed  from  re- 
straint. Real  liberty  for  all  could  not  exist  under  the 
operation  of  a  principle  which  recognizes  the  right  of  each 
individual  person  to  use  his  own,  whether  in  respect  to  his 
person  or  his  property,  regardless  of  the  injury  that  may 
be  done  to  others." 

6 


As  soon  as  the  sanitary  sciences  took  a  proud  place 
among  the  exact  sciences  (with  due  apologies  to  the  mathe- 
maticians) the  art  of  preventive  medicine  had  its  birth. 
Preventive  medicine  is  an  art  based  upon  many  sciences. 
It  is  an  art  that  has  reached  the  satisfactory  stage  when 
we  are  able  to  foretell  many  natural  events  in  the  epidem- 
iology of  disease  with  an  accuracy  not  dreamed  of  by  the 
prophets  of  old. 

Other  sciences  and  their  arts  have  passed  through  the 
same  evolution  that  is  so  evident  in  the  history  of  sanita- 
tion. All  science  in  its  infancy  and  immaturity  flounders 
and  crawls  in  a  negative  nursery.  The  dawn  of  a  positive 
program  foreshadows  the  day  of  useful  achievements. 
Sanitary  science  has  graduated  from  the  kindergarten  stage 
of  negation  and  is  now  passing  into  the  grammar  grade  of 
assertion.  We  are  now  witnessing  a  remarkable  renais- 
sance in  every  science,  resulting  in  a  transitional  period  of 
progress  which  characterizes  the  promising  though  perturb- 
ing period  in  which  we  live.  When  the  history  of  this  pe- 
riod is  written  the  historian  will  be  embarrassed  with  a 
wealth  of  material  progress  along  every  line  of  human  en- 
deavor, but  **when  earth's  last  picture  is  painted,  and  the 
tubes  are  twisted  and  dried,"  one  achievement  will  stand 
out  clearly  above  all  the  rest,  and  that  one  is  the  conquest 
of  disease. 

SOME  HYGIENIC  PALLAC5IES. 

The  new  hygiene  has  given  us  an  entirely  different  con- 
ception of  many  of  the  factors  that  enter  into  health  and 
disease.  It  has  exploded  many  a  world-old  fallacy.  We 
know,  for  example,  that  there  is  practically  no  more  danger 
from  sewer  gas  than  the  farmer  subjects  himself  to  on  his 
manure  pile.  The  old  bugaboo  of  sewer  gas  dies  hard. 
People  have  always  believed  and  still  naturally  cling  to  the 
notion  that  anything  that  smells  bad  must  be  detrimental 
to  health.  Science  has  demonstrated  that  our  sense  of  smell 
is  a  poor  sanitary  guide.  It  is  certainly  absurd  to  accuse 
the  emanations  from  defective  plumbing  of  being  the  source 
of  diphtheria,  typhoid  fever,  scarlet  fever,  sore  throat,  or 

any  other  infectioiL 

7 


Fomities  or  inanimate  things  were  formerly  supposed  to 
play  a  large  role  in  the  transmission  of  infection.  We  know 
that  in  fact  this  occasionally  happens,  especially  with  dis- 
eases spread  through  discharges  from  the  mouth  and  nose. 
Instead,  however,  of  accusing  letters,  books,  umbrellas, 
walls,  furniture,  merchandise,  and  other  unlikely  things, 
which  were  formerly  disinfected  or  destroyed,  we  now  think 
of  objects  recently  moistened  with  saliva,  such  as  drinking 
cups,  pencils,  toys,  towels,  as  well  as  food,  fingers  and  flies. 
Yellow  fever  was  believed  to  be  transferred  by  a  great 
variety  of  objects — coffee  sacks,  mattresses,  a  tress  of  hair, 
cigarettes  smuggled  in  the  false  bottom  of  a  trunk,  were  all 
accused  of  starting  epidemics  before  the  researches  of  Reed, 
Carroll,  Lazear  and  Agramonte.  Many  of  our  former  san- 
itary practices  now  seem  absurd  in  the  light  of  present-day 
knowledge.  While  quarantine  officer  in  Havana,  I  disin- 
fected, in  accordance  with  the  government  regulations,  and 
by  order  from  my  superior  officers  in  Washington,  every 
letter  that  left  the  island,  as  well  as  great  quantities  of 
wearing  apparel,  and  other  articles  suspected  of  carrying 
the  virus  of  yellow  fever.  I  even  used  to  disinfect  the  bal- 
last of  wooden  vessels,  and  in  the  case  of  rock  ballast, 
dipped  every  stone  separately  into  a  tub  of  bichloride  of 
mercury  for  fear  that  some  small  facet  would  escape  puri- 
fication. Again,  while  quarantine  officer  in  San  Francisco, 
before  the  knowledge  that  rats  and  fleas  are  the  chief  agent 
in  the  spread  of  plague,  I  used  to  disinfect  great  quantities 
of  foodstuffs  and  merchandise,  which  was  the  best  we  knew 
in  those  days.  I  well  remember  how  the  merchants  objected 
to  having  certain  Chinese  fruits  dipped  in  formalin.  When, 
however,  we  discontinued  the  process  as  useless  there  was 
still  greater  objection  because  the  merchants  had  discovered 
that  the  formalin  treatment  helped  to  preserve  some  of 
these  perishable  goods  for  a  considerable  period  of  time. 

Miany  a  person  obeys  the  call  ''back  to  nature"  with 
direful  results,  for  when  he  gets  into  nature's  solitude  he 
thinks  he  can  disregard  nature's  laws.  Sanitary  habits  are 
quite  as  important  in  the  wilds  as  in  the  tenements.  It 
especially  grieves  the  heart  of  the  sanitarian  to  note  how 

8 


frequently  people  contract  typhoid  fever  at  country,  moun- 
tain or  seashore  resorts.  The  excess  of  typhoid  fever  in  the 
autumn  now  goes  by  the  special  name  of  ''vacation  ty- 
phoid. ' '  The  unsanitary  conditions  found  in  many  sparsely 
settled  communities  temporarily  occupied  during  the  sum- 
mer season  often  challenge  the  conditions  found  in  military 
camps  during  the  bow  and  arrow  age.  Before  people  leave 
the  sanitary  security  of  a  well-guarded  city  for  vacation 
grounds,  they  should  demand  a  bill  of  health  from  the 
health  officer. 

Sometimes  science  will  change  our  views  in  a  revolu- 
tionary manner,  but  these  altered  views  may  not  materially 
change  the  practice  of  our  art. 

Thus  our  entire  conception  of  ventilation  has  changed, 
owing  to  the  fact  that  we  now  do  not  believe  that  fresh  air 
is  particularly  necessary  in  order  to  furnish  us  with  more 
oxygen  or  to  remove  the  slight  excess  of  carbon  dioxide. 
It  is  plain  that  it  is  heat  stagnation  that  makes  us  feel  so 
uncomfortable  in  a  poorly  ventilated  room  rather  than  any 
change  in  the  chemical  composition  of  the  air.  It  has  been 
made  perfectly  clear  from  the  work  of  Flugge  that  one  of 
the  chief  functions  of  fresh  air  is  to  help  our  heat-regulat- 
ing mechanism  maintain  the  normal  temperature  of  the 
body.  It  is  necessary  to  have  some  2000  to  3000  cubic  feet 
of  air  an  hour  to  maintain  our  thermic  equilibrium — ^just 
the  amount  that  was  formerly  stated  to  be  necessary  to 
dilute  the  carbon  dioxide  and  supply  fresh  oxygen.  The 
practice  of  ventilation,  therefore,  has  not  altered  so  much 
as  has  our  reason  for  attaching  importance  to  clean,  cool, 
moving  air,  which  has  completely  changed. 

One  of  the  fallacies  that  has  fallen  is  the  relation  of  the 
air  to  the  spread  of  infection.  The  virus  of  most  commu- 
nicable diseases  was  believed  to  be  in  the  expired  breath,  or 
exhaled  as  emanations  of  some  sort  from  the  body.  These 
emanations  were  said  to  be  carried  long  distances,^miles — 
on  the  wind.  The  easiest,  and  therefore  the  most  natural 
way,  to  account  for  the  spread  of  epidemic  diseases  was  to 
consider  them  as  air-borne.  Nowadays  the  sanitarian  pays 
little  heed  to  infection  in  the  air  except  in  droplet  infection, 
and  the  radius  of  danger  in  the  fine  spray  from  the  mouth 

9 


and  nose  in  coughing,  sneezing  and  talking  is  limited  to  a 
few  feet  or  yards  at  most.    The  more  the  air  is  studied  the 
more  it  is  acquitted  as  a  vehicle  for  the  spread  of  commu- 
nicable diseases. 

It  was  a  great  surprise  when  bacteriologists  demonstrated 
that  the  expired  breath  ordinarily  contains  no  bacteria. 
Most  microorganisms,  even  if  wafted  into  the  air  soon  die 
on  account  of  the  dryness,  and  especially  if  exposed  to  sun- 
shine. The  relation  of  the  air  to  infection  is  nowhere  better 
illustrated  than  in  the  practice  of  surgery.  At  first  Lister 
and  his  followers  attempted  to  disinfect  the  air  in  contact 
with  the  wound  by  carbolic  sprays.  Now  the  surgeon  pays 
no  heed  to  the  air  of  a  clean  operating  room,  but  ties  a  piece 
of  gauze  over  his  mouth  and  nose,  and  also  over  his  hair,  to 
prevent  infective  agents  from  falling  into  the  wound  from 
these  sources. 

A  similar  revolution  is  recorded  in  almost  every  chapter 
of  the  great  book  of  preventive  medicine.  With  this  in- 
crease of  knowledge  has  resulted  a  corresponding  increase 
in  efficiency.  We  are  now  enabled  to  apply  our  preventive 
measures  with  an  assurance  of  success  not  hitherto  possible. 
It  is  quite  easy  to  work  in  the  midst  of  a  raging  cholera 
epidemic  without  contracting  the  disease;  this  was  clearly 
shown  in  Hamburg  in  1892.  It  is  still  easier  to  nurse  and 
attend  patients  with  smallpox  without  taking  the  infection. 
A  well-screened  yellow  fever  hospital  is  the  safest  place  in 
an  outbreak,  as  was  demonstrated  during  the  last  epidemic 
in  New  Orleans  in  1905.  It  is  quite  practical  with  bac- 
terial vaccines  to  raise  our  immunity  to  typhoid  fever, 
plague,  and  a  number  of  other  infections.  Furthermore, 
the  methods  of  a  clean  hygienic  life  are  better  understood 
than  formerly. 

Milk  is  responsible  for  outbreaks  of  typhoid  fever,  scar- 
let fever,  diphtheria,  septic  sore  throat,  and  is  also  respon- 
sible for  a  certain  amount  of  tuberculosis  and  infantile 
diarrhea.  These  facts  make  it  quite  certain  that  many 
diseases  formerly  attributed  to  pollution  of  the  soil,  to  efflu- 
via from  broken  drains,  or  some  other  indeterminate  cause, 
were  in  reality  due,  in  part  at  least,  to  impure  milk.    Milk, 

10 


then  as  now,  must  have  been  a  factor  for  the  spread  of  the 
agents  of  infection.  It  took  a  long  time  to  find  out  that 
these  infections  may  be  transmitted  in  milk  and  that  the 
danger  may  be  neutralized  by  such  a  simple,  harmless  and 
efficient  process  as  pasteurization. 

Many  people  delude  themselves  with  the  false  hope  that 
there  is  some  drug  to  cure  every  disease.  The  specific 
remedies  may  be  counted  on  the  fingers  of  our  hands. 
Ycry  few  therapeutic  agents  rival  quinine  for  malaria, 
salvarsan  for  syphilis,  or  antitoxin  for  diphtheria,  and 
even  these  must  be  properly  administered  in  order  to 
obtain  satisfactory  results.  The  common  belief  that  there 
is  some  drug  that  will  cure  every  disease  is  fostered  by 
unscrupulous  persons  who  boldly  advertise  ''sure  cures'' 
for  rheumatism,  pneumonia,  cancer,  tuberculosis,  diabetes, 
and  Bright 's  disease.  These  fallacies  quickly  disappear 
when  people  become  better  informed  as  to  the  limitations 
of  the  pharmacopeia — quackery  will  then  be  less  pros- 
perous. 

Many  other  fallacies  are  fostered.  The  ozone  myth  is 
one  of  them.  Ozone  is  an  irritating  and  poisonous  gas.  It 
conceals  faults  in  ventilation  while  not  correcting  them. 
Ozone  will  destroy  mammalian  life  more  quickly  than  it 
will  destroy  bacterial  life,  hence  it  has  no  useful  disin- 
fecting power  in  occupied  rooms.  The  sanitarian  classifies 
ozone  as  a  poison,  not  as  a  purifier,  and  believes  that  the 
recent  ozonizing  machines  advocated  for  offices,  schools, 
theatres,  and  other  places,  are  mischievous. 

All  those  who  have  given  thoughtful  study  to  the  pure 
food  situation  as  it  now  exists  are  agreed  that  the  pure 
food  question  is  an  economic  rather  than  a  health  prob- 
lem. To  discuss  this  and  other  fallacies  would  require 
endless  time.    Only  a  few  are  mentioned  as  examples. 

A  deeper  insight  into  the  causes  and  method  of  trans- 
mission of  disease  has  robbed  infection  of  the  terror  with 
which  the  dread  of  epidemics  once  staggered  mankind. 
For  graphic  descriptions  read  Defoe's  ''Journal  of  the 
Plague  Year,"  or  S.  Weir  MitcheU's  "A  Red  City."  It 
is  difficult  for  those  who  have  not  witnessed  the  panic  of  a 

11 


fever-stricken  city  to  realize  the  terror,  the  flight,  and  the 
paralysis  of  trade,  all  due  to  a  helplessness  and  hopeless- 
ness, the  result  of  ignorance.  Knowledge  has,  therefore, 
given  us  confidence  that  has  conquered  a  fear  of  infection 
as  supernatural  and  has  mastered  a  superstitious  dread 
of  its  mysteries.  This  conquest  is  one  of  the  milestones 
which  marks  the  advance  of  mankind. 

CONQUEST   OF  THE  FEAR  OF   THE   SUPERNATURAL. 

It  is  difficult  to  measure  the  advance  made  by  mankind ; 
in  fact,  it  is  even  doubted  whether  man  has  made  any  real 
progress  since  the  dawn  of  written  history.  I  am  op- 
timistic enough  to  believe  that  man  has  made  great  strides 
physically,  mentally  and  spiritually.  Physically,  man  is 
better  off  on  account  of  a  better  understanding  of  the 
world  in  which  he  lives.-  Mentally,  he  is  superior  to  his 
remoter  ancestors  on  account  of  a  clearer  understanding  of 
truth  and  how  to  find  it,  and  both  these  facts  have  greatly 
influenced  the  spiritual  yearnings  that  distress  every  soul 

We  no  longer  personify  everything  about  us  with  a 
childlike  anthropomorphism,  although  there  is  still  a  uni- 
versal tendency  among  mankind,  as  pointed  out  nearly 
one  hundred  years  ago  by  David  Hume,  whose  philosophy 
gains  strength  with  advancing  age,  to  conceive  all  beings 
like  ourselves,  and  to  transfer  to  every  object  those  quali- 
ties with  which  we  are  familiarly  acquainted.  We  now 
look  out  into  the  world  unafraid,  and  with  a  faith  born  of 
a  knowledge  of  nature  and  her  laws.  The  scientific  spirit 
has  freed  us  from  the  trammels  of  tradition;  we  are  now 
permitted  to  question,  invited  to  doubt,  and  today  we  boldly 
investigate,  even  with  public  approval,  forbidden  subjects 
of  yesterday. 

It  is  so  plain  to  us  now  that  the  length  of  a  vibrating 
string  determines  the  sound  it  produces  that  it  is  difficult 
for  us  to  put  ourselves  in  the  place  of  those  who  formerly 
thought  that  they  heard  the  voice  of  Eolus.  We  know 
the  lightning  is  not  the  wrath  of  Jove,  the  eclipse  is  not  a 
shadow  of  portending  evil,  and  the  wind  *  *  bloweth  where  it 
listeth''  on  account  of  differences  in  weight  between  cold 

12 


and  warm  gases.  Knowledge  has  begotten  wisdom,  and  wis- 
dom has  given  us  confidence  that  would  have  been  regarded 
as  rashness,  if  not  impiety,  in  other  days. 

Best  of  all,  perhaps,  is  that  definite  information  concern- 
ing the  agents  of  infection  which  at  one  stroke  has  taken 
them  out  of  the  supernatural. 

The  influence  of  some  supernatural  power  with  refer- 
ence to  disease  still  lingers  in  the  minds  of  many  who  take 
the  fatalistic  attitude  that  if  we  are  going  to  be  sick  we  are 
going  to  be  sick,  and  nothing  that  man  can  do  will  avert  it. 
The  very  names  of  a  number  of  diseases  give  sanction  to 
this  belief.  Thus  erysipelas  was  long  called  St.  Anthony's 
fire,  and  scrofula  the  King's  evil.  Chorea  is  still  called  St. 
Vitus'  dance.  Persons  with  epilepsy  or  insanity  were  be- 
lieved to  be  possessed  of  the  devil,  and  many  charms  were 
worn  to  guard  against  the  evil  spirits,  and  many  strange 
devices  were  used  to  dispossess  them.  There  is  an  account 
of  the  plague  in  Rome  about  the  time  of  Esculapius  in 
which  it  is  related  that  great  fires  were  built  in  the  streets, 
and  a  great  noise  was  made  in  order  to  frighten  away  the 
demons.  The  plague,  in  fact,  soon  ceased,  but  we  are  now 
inclined  to  think  it  was  because  the  continued  fires  and 
alarum  scared  away  the  rats  rather  than  the  evil  spirits. 

The  fatalism  that  still  binds  the  minds  of  men  was  well 
shown  in  the  hookworm  campaign.  The  greatest  barrier 
met  with  in  eradicating  hookworm  disease  was  the  preju- 
dice and  ignorance  of  the  people  and  profession.  Until 
this  was  overcome  the  measures  to  help  the  infected  people 
were  fruitless. 

A  knowledge  of  the  natural  history  of  disease  has  drawn 
the  teeth  of  many  an  ancient  mythical  dragon.  Certain 
diseases  recur  annually  like  the  deciduous  plants.  We  have 
our  annual  crop  of  typhoid  fever  just  as  we  have  our  an- 
nual crop  of  thistles;  we  have  tuberculosis  perennially 
just  as  we  have  evergreen  firs  and  balsams.  The  appear- 
ance and  disappearance  of  some  diseases  can  be  predicted 
with  the  same  certainty  as  the  seasonal  appearance  and  dis- 
appearance of  plants.  Epidemics  of  measles  in  Richmond, 
Va.,  have  been  foretold  with  the  same  certainty  as  the  de- 
cline of  water-borne  typhoid  fever  in  Pittsburg. 

13 


Formerly,  when  yellow  fever  broke  out  in  our  Southland, 
the  fever-stricken  city  was  paralyzed  both  with  fear  of  the 
disease  and  with  the  terrors  of  a  shotgun  quarantine.  Now, 
yellow  fever  cases  arriving  at  Havana  are  fearlessly  carried 
through  the  city  in  a  screened  ambulance  to  Las  Animas 
Hospital.  We  need  no  longer  fear  plague,  typhus  fever, 
relapsing  fever,  and  other  maladies  in  the  way  they  once 
terrorized  a  less  informed  and  less  sanitary  age. 

The  definite  knowledge  concerning  most  infections  and 
the  natural  laws  governing  their  transmission  has  given  us 
a  confidence  that  has  properly  robbed  these  diseases  of  the 
supernatural  dread  which  once  invested  them.  We  know 
that  the  inscription,  **Died  by  the  grace  of  God''  on  many 
a  tombstone,  should  read, '  *  Died  by  the  disgrace  of  infected 
milk"  or  polluted  water,  or  some  other  preventable  factor. 

Every  scientific  discovery  contributes  to  the  physical,  in- 
tellectual and  moral  betterment  of  the  world,  but  the  dis- 
coveries in  preventive  medicine  have  made  the  lot  of  man 
so  much  easier,  and  this  life  so  much  safer,  that  he  has 
more  time  than  ever  to  think  of  his  neighbor  and  to 
share  his  blessings  with  him.  More  than  this,  preventive 
medicine  has  quickened  the  coming  of  the  brotherhood  of 
man,  for  it  has  pricked  his  conscience  in  an  extraordinary 
way. 

A   SANITARY   CONSCIENCE. 

One  of  the  most  remarkable  developments  of  this  age 
in  which  we  live  is  the  awakening  of  a  sanitary  conscience. 
It  is  a  new  thought  in  the  mind  of  many  a  man  that  the 
care  of  the  body  and  cleanliness  of  surroundings  is  a  very 
considerable  factor  in  the  comfort,  safety,  and  even  the  life 
and  health  of  his  fellowmen.  The  sense  of  moral  good- 
ness which  comes  from  a  clean  and  hygienic  life  is  part  of 
the  doctrine  of  sanitary  righteousness.  Preventive  medi- 
cine teaches  that  we  must  not  only  safeguard  our  own 
bodies  against  infection,  and  keep  our  own  surroundings 
clean  for  our  own  sakes,  but  quite  as  much  for  our  neigh- 
bor's sake.  It  teaches  the  lesson  of  the  unselfishness  of 
community  interest  and  has  been  a  potent  biological  factor 

14 


which  underlies  the  present  trend  towards  socialism.  One 
man  alone  cannot  fight  the  fight  against  the  common  foe — 
infection ;  it  takes  the  combined  and  intelligent  cooperation 
of  the  community. 

One  of  the  best  instances  that  comes  to  mind  is  the  case 
of  vaccination  for  smallpox,  which  was  the  first  and  remains 
one  of  the  great  achievements  in  preventive  medicine.  Vac- 
cination affords  a  very  high  degree  of  protection  to  the  in- 
dividual and  a  well-nigh  perfect  protection  to  the  commu- 
nity. Vaccination  and  revaccination  systematically  and 
generally  carried  out  will  completely  erase  smallpox  from 
a  nation.  In  other  words,  while  the  individual  protection 
is  not  always  perfect,  the  communal  protection  is  absolute. 
To  remain  unvaccinated,  therefore,  is  selfish,  in  that  by  so 
doing  a  person  steals  a  certain  measure  of  protection  from 
the  community  on  account  of  the  barrier  of  vaccinated 
persons  around  him.  In  England  the  Conscience  Clause 
permits  many  persons  to  remain  unvaccinated  because  the 
law  exempts  persons  whose  religious  scruples  forbid  com- 
pliance therewith.  Our  own  Supreme  Court  wisely  forbids 
any  such  exemption  in  states  having  vaccination  laws. 

No  man  has  the  right  to  endanger  his  fellowmen  with  in- 
fection any  more  than  he  has  the  right  to  endanger  him 
with  physical  injury.  The  Supreme  Court  of  Minnesota, 
Dec.  23,  1910,  in  the  case  of  a  water-borne  outbreak  of 
typhoid  fever,  held  that '  *  the  state  is  liable  if  damages  can 
be  proved. ' '  This  decision  places  the  responsibility  where 
it  should  be.  Citizens  are  evidently  as  much  entitled  to 
reasonable  sanitary  protection  as  they  are  to  police  pro- 
tection, or  to  protection  from  accidents  at  grade  crossings. 
It  is  ^  fortunate  day  for  preventive  medicine  when  the  priu- 
ciple  is  recognized  that  sanitary  negligence  is  just  as 
culpable  as  the  negligence  which  fails  to  place  a  red  flag 
by  day  or  a  red  lantern  by  night  to  guard  against  a  pitfall 
in  the  public  highway.  Retumiag  again  to  vaccination,  we 
find  that  the  experience  of  over  one  hundred  years  clearly 
demonstrates  its  benefits,  and  we  see  that  Germany  has 
taught  the  world  how  to  apply  the  known  facts.  If  the 
entire  world  would  follow  the  example  of  Germany  then 

15 


Thomas  Jefferson's  prophecy  to  Jenner  that  '* future  na- 
tions will  know  by  history  alone  that  the  loathsome  small- 
pox has  existed  and  by  you  has  been  extirpated,"  would 
soon  be  fulfilled.  Sanitarians  know  that  it  would  be  much 
simpler  to  render  smallpox  extinct  than  it  was  to  stamp 
out  yellow  fever  from  the  Canal  Zone. 

In  the  case  of  rabies  we  have  another  instance  in  which 
the  sentiment  of  selfishness  of  man  permits  his  fellows  to 
suffer  from  preventable  disease.  A  better  understanding 
of  the  facts  would  soon  make  it  plain  that  death  from 
hydrophobia  is  as  unnecessary  as  death  from  an  unpro- 
tected cogwheel.  England  has  eliminated  rabies,  and  Aus- 
tralia has  kept  it  out  through  muzzling  ordinances  and 
quarantine  on  dogs.  Muzzling  temporarily  inconveniences 
the  dogs,  but  in  the  end  protects  dogs  as  well  as  man  and 
other  animals  from  this  communicable  infection. 

The  laws  of  biology  have  a  direct  bearing  upon  our  daily 
life,  and  a  correct  understanding  of  these  laws  helps  us  not 
alone  to  a  longer  and  healthier,  but  to  a  better  life.  Many 
ethical  questions  that  trouble  our  complex  age  can  also  be 
solved  by  an  intelligent  understanding  of  biology,  just  as 
many  material  questions  relating  to  health  and  disease 
depend  upon  a  deeper  insight  into  the  medical  sciences. 

All  enduring  progress  must  be  based  upon  morality, 
but  our  very  interpretation  of  morality,  as  it  influences  our 
conduct  of  life  and  our  relations  to  our  fellowmen,  is  based 
upon,  and  guided  in  no  small  degree  by  a  correct  under- 
standing of  the  world  about  us.  It  is  plain  to  the  student 
of  biology  that  the  rich  harvest  of  facts  garnered  by  the 
experimental  method  in  all  the  fields  of  science  during 
recent  years  has  gradually  but  inexorably  impressed  itself 
upon  the  changing  code  of  ethics  of  all  civilized  nations. 
The  criminal  of  yesterday  derided  and  jailed  is  the  patient 
of  today  sent  to  the  hospital  for  treatment ;  the  vicious  in- 
dividual or  the  incompetent  moron  is  not  now  regarded  as 
deserving  the  finger  of  scorn  so  much  as  he  is  entitled  to 
the  humanity  that  recognizes  the  condition  as  one  of  im- 
perfect protoplasm,  caused  by  a  natural  limitation  due 
perhaps  to  hereditary  faults  in  his  ancestors;  the  insane 

16 


are  no  longer  laughed  at  as  bewitched,  but  treated  with  a 
consideration  and  humanity  based  upon  a  clearer  under- 
standing of  their  diseased  states.  How  different  all  this 
is  from  the  time  audiences  roared  at  the  antics  of  King 
Lear  as  a  comedy  character,  and  people  visited  Bedlam  as  a 
source  of  amusement.  A  drunken  character  on  the  stage  is 
no  longer  greeted  with  peals  of  laughter,  but  with  a  feeling 
akin  to  sorrow  and  disgust.  We  no  longer  declaim  that  all 
men  are  created  free  and  equal,  for  we  know  that  they  are 
bound  by  their  protoplasmic  makeup,  and  unequal  in  their 
powers  and  responsibilities. 

The  responsibility  of  individuals  and  the  limitations  of 
an  imperfect  human  machine  are  much  clearer  to  us  than 
formerly.  Infection  is  no  longer  regarded  as  a  punishment 
for  sin,  or  even  sin  itself,  much  less  a  supernatural  visita- 
tion, but  simply  a  conflict  between  two  beiags,  one  the  host 
and  the  other  the  parasite.  In  one  sense  this  conflict, 
though  less  obvious,  is  not  essentially  different  from  the 
conflict  between  a  rattlesnake  and  his  prey.  The  battle  be- 
tween host  and  parasite  results  in  a  reaction  in  the  host 
and  this  reaction  we  call  an  iafectious  disease.  The  various 
elements  which  make  up  this  conflict,  such  as  the  mode  of 
attack  of  the  parasite  and  the  means  of  defense  of  the  host, 
have  been  carefully  studied.  A  sharp  defense  on  the  part 
of  the  host  will  sharpen  the  claws  of  the  parasite  in  accord- 
ance with  the  laws  of  the  survival  of  the  fittest,  and  thus 
increase  the  reaction  or  the  intensity  of  the  disease.  If  the 
parasite  is  unduly  aggressive  and  virulent,  and  thus  kills 
its  host  too  quickly,  it  defeats  its  own  object,  for  the  para- 
site is  in  the  position  of  the  rats  on  a  ship.  It  serves  small 
purpose  to  scuttle  the  ship  unless  there  is  some  means  of 
passing  to  another  ship.  The  mode  of  transference  of  the 
parasite  is  therefore  of  vital  importance  to  the  parasite,  and 
of  great  practical  concern  to  the  host.  The  infectious  dis- 
eases, then,  represent,  only  one  phase  iu  a  complex 
series  of  events  in  which  parasite  and  host  are  inter-related, 
not  only  as  rats  on  a  ship,  but  as  seed  and  soil. 

The  cornucopia  of  preventive  medicine  is  not  overflowing 
but  is  filling  up  with  blessings  of  various  sorts.     One  of 

17 


the  most  important  when  gauged  by  practical  results  is  a 
better  understanding  of  the  sources  of  infection  and  their 
modes  of  transference.  It  is  much  more  important  for  the 
health  officer  to  know  the  ways  in  which  the  virus  is  trans- 
mitted from  one  person  to  the  next  than  to  Imow  the  causes 
of  disease.  Thus  with  yellow  fever  we  are  enabled  to  pre- 
vent it  or  check  an  epidemic,  although  still  ignorant  of  its 
cause. 

SOURCES    OF   INFECTION    AND    MODES   OF    TRANSFERENCE. 

There  are  two  great  sources  of  the  communicable  diseases 
of  man,  viz.,  man  himself,  and  the  lower  animals.  Most  of 
the  communicable  diseases  of  man,  especially  those  which 
occur  in  epidemic  form,  are  peculiar  to  man.  This  is  the 
case  with  typhoid  fever,  cholera,  leprosy,  malaria,  yellow 
fever,  syphilis,  mumps,  measles,  scarlet  fever,  typhus  fever, 
infantile  paralysis,  cerebrospinal  fever,  smallpox,  chicken- 
pox,  relapsing  fever,  dengue,  and  even  tuberculosis  in  large 
part.  It  is  quite  true  that  some  of  these  infections  may  be 
communicated  to  the  lower  animals  under  experimental 
conditions,  but  they  do  not,  as  a  rule,  occur  in  them  under 
natural  conditions.  In  other  words,  most  of  the  communi- 
cable diseases  from  which  man  suffers  are  specific ;  the  de- 
gree of  specificity  varying  slightly  with  the  different 
infections. 

It  is,  therefore,  plain  that  man  is  the  great  source  and 
reservoir  of  human  infections.  Man  is  man's  greatest  foe 
in  this  regard.  The  fact  that  most  of  the  communicable 
diseases  must  be  fought  in  the  light  of  an  infection  spread 
from  man  to  man  is  one  of  the  most  important  advances  in 
preventive  medicine.  This  new  thought  has  crystallized 
out  of  a  mass  of  work  in  the  sanitary  sciences  during  the 
past  decade,  from  researches  upon  tuberculosis,  typhoid 
fever,  cerebrospinal  meningitis,  and  other  communicable 
diseases.  Formerly  sanitarians  regarded  the  environment 
as  the  main  source  of  infection.  We  now  know  that 
water,  soil,  air,  and  food  may  be  the  vehicles  by  which  the 
viruses  of  the  communicable  diseases  are  sometimes  trans- 
ferred— that  is,  they  are  media  of  conveyance  rather  than 

18 


sources  of  infection.  Most  of  the  microorganisms  causing 
the  communicable  diseases  of  man  are  frail  and  soon  die 
in  our  environment,  as  in  the  air,  soil,  or  water.  Most  of 
them  are  obligate  pathogens  and  cannot  or  do  not  grow 
or  multiply  in  our  environment. 

From  the  lower  animals,  particularly  the  domesticated 
animals,  man  contracts  a  number  of  infections.  Thus  we 
contract  rabies  from  dogs,  plague  from  rats,  glanders  from 
horses,  trichinosis  from  hogs,  malta  fever  from  goats,  an- 
thrax and  foot-and-mouth  disease  from  cattle,  tuberculosis, 
in  part,  from  cattle ;  tapeworms  and  other  animal  parasites 
from  the  meat  of  fish,  fowl,  and  mammals.  Various  skin 
parasites  are  also  contracted  from  the  lower  animals,  as 
ringworm  from  cats.  The  number  of  diseases,  however, 
contracted  from  the  lower  animals,  and  the  extent  of  their 
ravages  are  notably  less  than  those  contracted  from  man 
himself. 

The  knowledge  that  most  infections  are  spread  rather 
directly  from  man  to  man  combines  the  forces  of  sociology 
with  those  of  preventive  mediciue.  The  task  of  preventive 
medicine  is  thereby  rendered  much  more  difficult  from  the 
fact  that  the  control  of  most  infections  depends  upon  the 
control  of  man  himself.  The  elimination  of  smallpox,  and 
that  still  worse  plague,  the  great  pox,  illustrates  the  well- 
known  principle  in  preventive  medicine  that  it  is  much 
more  difficult  to  control  a  disease  transmitted  directly  from 
man  to  man  than  a  disease  transmitted  by  an  intermediate 
host  or  one  contracted  from  the  lower  animals,  or  one  trans- 
ferred to  us  from  our  environment.  We  have  a  certain 
amount  of  control  over  our  surroundiugs,  and  we  have 
dominion  over  the  lower  animals,  but  the  control  of  man 
requires  the  consent  of  the  governed.  Thus  it  is  easier  to 
stamp  out  yellow  fever  than  to  control  typhoid  fever.  It 
is  easier  to  suppress  malaria  than  tuberculosis,  rabies  than 
influenza,  trichinosis  than  syphilis.  Cattle  appear  to  be 
mutely  thankful  when  protected  by  iuoculation  against 
blackleg  or  anthrax,  but  man  rebels  against  one  of  the  best 
of  all  specifics — ^vaccination  agaiast  smallpox.  The  fact 
that  man  is  the  chief  source  and  reservoir  of  most  of  his 

19 


own  infections  adds  greatly  to  the  scope  and  difficulties  of 
public  health  work,  and  often  makes  the  prevention  of  dis- 
ease depend  upon  social  changes.  In  this  sense  preventive 
medicine  has  become  one  of  the  important  factors  in 
sociology. 

The  agents  of  infection  may  take  various  routes  of  trans- 
ference from  man  to  man  or  from  animal  to  man.  These 
routes  are  spoken  of  as  the  modes  of  infection,  the  mode  of 
transference,  or  sometimes  as  the  vehicles  of  infection. 
Formerly  they  were  spoken  of  as  the  **  channels  of  infec- 
tion, ' '  but  now  we  restrict  that  term  to  the  special  channel 
by  which  the  infection  enters  the  body.  Thus  the  channel 
of  infection  in  tuberculosis  may  be  the  respiratory  tract, 
the  digestive  system,  or  the  skin ;  whereas  the  mode  of  in- 
fection is  from  tuberculous  sputum,  either  by  direct  con- 
tact, by  droplet  infection,  or  through  milk  or  some  other 
medium  of  conveyance. 

The  modes  of  transference  may  be  grouped,  for  con- 
venience, under  three  general  heads:  (1)  direct,  (2)  indi- 
rect, and  (3)  through  an  intermediate  host.  In  the  great 
majority  of  cases,  however,  the  virus  is  transferred  more  or 
less  directly  by  what  is  now  known  as  contact  infection. 
In  many  instances  the  virus  is  transferred  indirectly 
through  water,  food,  soil,  air,  etc.  In  a  large  group  of  dis- 
eases the  transfer  is  through  an  intermediate  host  which 
furnishes  the  growing  list  of  insect-borne  diseases.  The 
above  facts  bring  out  a  significant  distinction  between 
hygiene  and  sanitation. 

HYGIENE  VERSUS   SANITATION. 

We  now  know  that  purifying  water  and  pasteurizing 
milk  will  decrease  but  will  not  delete  typhoid  fever.  Re- 
sidual typhoid  fever  must  be  fought  in  the  light  of  an 
infection  spread  from  man  to  man,  that  is,  in  the  light  of 
a  contagious  disease.  It  has  often  been  said  that  typhoid 
fever  is  infectious  but  not  contagious.  There  is  much  mis- 
chief in  that  statement,  for  it  is  clear  that  typhoid  is  both 
contagious  and  infectious,  or,  as  we  prefer  to  say,  com- 
municable.    These  words,  '* contagious ' '  and  ''infectious*' 

20 


are  popular  terms  lacking  precise  definition,  and  the  dis- 
tinction serves  no  useful  purpose.  Contagious  diseases 
may  be  infectious  and  infectious  diseases  may  be  con- 
tagious.   The  distinction  is  artificial  and  should  be  dropped. 

Modem  science  teaches  that  tuberculosis  is  both  con- 
tagious and  infectious,  but  not  hereditable,  as  was  formerly 
supposed.  Tuberculosis  is  an  example  of  a  disease  that 
must  be  fought  along  both  hygienic  and  sanitary  lines,  that 
is,  hygienic  living  to  improve  the  resistance  against  the 
infection  and  sanitary  habits  and  surroundings  to  diminish 
the  chances  of  contracting  the  virus. 

A  distinction  is  therefore  growing  up  between  the  old 
terms  ''hygiene"  and  "sanitation,"  which  are  the  Greek 
and  Latin  equivalents  for  health.  More  and  more  are  we 
limiting  the  word  "hygiene"  to*the  person,  and  "sanita- 
tion'' to  the  environment.  Hygiene  is  personal,  sanitation 
impersonal.  Thus  we  speak  of  the  hygiene  of  the  school 
children,  but  the  sanitation  of  the  school  buildings.  We 
speak  of  the  sanitation  of  the  Panama  Canal  Zone,  but  the 
hygienic  condition  of  the  workers.  Before  the  present 
renaissance  of  the  sanitary  sciences  these  two  terms,  "hy- 
giene" and  "sanitation"  were  used  more  or  less  inter- 
changeably. The  distinctions  are  growing  necessary  as  a 
result  of  our  enlarged  knowledge. 

CLEANLINESS   THE    HEART    AND    SOUL   OP    SANITATION. 

Although  science  has  shown  the  increased  importance  of 
a  personal  hygiene,  it  has  not  diminished  the  value  of  im- 
personal sanitation.  Environment  has  been  shown  to  have 
very  little  to  do  with  the  spread  of  a  large  number  of  dis- 
eases, of  which  scarlet  fever,  diphtheria,  whooping-cough, 
measles,  smallpox,  syphilis,  mumps,  cerebrospinal  fever 
may  be  taken  as  examples.  In  view  of  these  facts  there  has 
been  a  tendency  on  the  part  of  some  health  officers  to 
exaggerate  the  importance  of  the  person  in  the  transfer  of 
disease,  and  to  negelect  the  environment.  There  is  a 
large  and  important  group  of  diseases  in  which  the  care 
and  cleanliness  of  our  surroundings  are  of  great  concern. 
This  class  is  represented  by  those  infections  spread  by  the 

21 


alvine  discharges,  such  as  typhoid  fever,  cholera,  hookworm 
disease,  dysentery,  and  others  caused  by  intestinal  para- 
sites. These  diseases  were  formerly  called  ''filth  diseases." 
That  term  is  dying  out  since  the  domination  of  a  personal 
hygiene  over  sanitation.  At  one  time  the  conception  of 
the  filth  diseases  reached  the  dignity  of  a  special  name— 
the  ''pythogenic  theory" — ^first  propounded  by  Murchison 
in  1858.  Although  Murchison's  conceptions  were  quite 
wrong,  we  should  not  forget  that  typhoid  fever  is  really  a 
filth  disease — at  least  a  filthy  disease,  because  every  case 
means  that  a  short  circuit  has  been  established  between  the 
discharges  from  one  person  and  the  mouth  of  another. 

The  mistake  should  not  be  made  that  simply  because  dirt 
does  not  breed  disease  it  may  be  neglected,  because  the 
filthy  garbage  can  does  not  emit  diphtheria  it  may  be  tol- 
erated, and  because  the  foul  odors  from  decomposing  or- 
ganic matter  do  not  carry  with  them  the  effluvium  of  any 
known  disease,  they  may  be  permitted.  No  mistake  could 
be  greater.  Cleanliness  is  still  next  to  godliness,  and  it  is 
just  as  important  from  the  standpoint  of  personal  hygiene 
as  ever.  Cleanliness  of  mind  and  body,  cleanliness  of  home 
and  surrroundings,  cleanliness  of  city  and  country,  cellar 
and  garret,  wharf  and  shop,  markets  and  roads,  cleanliness 
of  the  air  we  breathe,  water  we  drink,  food  we  eat,  and 
habits  we  cultivate,  are  the  substantial  foundation  blocks 
for  an  enduring  structure  of  preventive  medicine.  The 
dearly  bought  experience  of  the  ages  has  taught  mankind 
the  lesson  that  cleanliness  makes  for  health,  while  the  re- 
verse encourages  disease.  Only  two  years  ago  a  well  di- 
rected and  energetic  sanitary  campaign  practically  abol- 
ished typhoid  fever  from  Yakima  County,  Washington, 
where  the  disease  was  unduly  prevalent,  simply  by  a  "  gen- 
eral cleaning  up."  This  demonstration  was  one  of  the 
great  object  lessons  in  modern  sanitation  that  has  not  been 
given  the  attention  it  deserves. 

Our  conception  of  cleanliness  has  greatly  changed  with 
our  advance  in  knowledge  of  the  kinds  of  dirt,  the  degree 
of  dirtiness,  and  the  nature  of  these  dangers.  "We  can  no 
longer  be  satisfied  with  visible  or  esthetic  cleanliness,  but 

22 


must  insist  upon  biological  cleanliness.  A  tetanus  spore 
upon  the  shining  blade  of  a  surgeon's  knife  makes  that  in- 
strument filthy,  whereas  many  such  spores  on  the  skin  of  a 
chicken  may  be  harmless  when  ingested.  "We  cannot  see 
the  infection  upon  the  common  drinking  cup,  upon  the 
roller  towel,  upon  the  point  of  a  pencil  that  has  just  been 
moistened  with  saliva,  or  in  water,  milk,  or  food,  although 
we  well  know  the  danger  of  such  invisible  ''dirt"  that  these 
objects  may  harbor. 

It  requires  a  bacteriologist  to  tell  the  difference  between 
clean  dirt  and  dirty  dirt.  We  lack  a  sixth  sense,  or  micro- 
scopical eye  to  see  and  distinguish  the  harmful  germs. 
Furthermore,  cleanliness,  in  the  modern  understanding  of 
the  term,  involves  the  absence  of  flies,  fleas,  mosquitoes, 
bedbugs,  lice,  rats,  mice,  and  all  sorts  of  vermin.  "We 
must  therefore  practice  scrupulous  cleanliness  and  educate 
the  people  to  the  biological  meaning  of  this  term.  Long 
experience  has  taught  the  lesson  that  cleanliness  offers  a 
mode  of  protection  against  disease,  that  clean  surroundings 
are  apt  to  be  free  from  infection,  and  that  clean  food  is 
apt  to  be  safe  food. 

Before  the  rise  of  a  personal  hygiene  the  health  officer 
was  a  general  scavenger.  His  chief  duty  was  to  abate  nui- 
sances, collect  garbage,  inspect  plumbing,  and  look  after 
pesthouses  and  lazarettos.  The  sanitarian  now  knows  that 
rubbish,  manure,  and  organic  wastes  of  all  kinds  are  not 
sources  of  infection,  although  they  may  favor  the  spread  of 
infection.  Vermin  breed  and  feed  where  dirt  of  this 
nature  is  tolerated.  Rubbish  in  vacant  lots,  or  back  yards, 
in  alleys,  in  cellars,  garrets,  and  other  places  may,  there- 
fore, be  taken  as  an  index  of  the  failure  to  appreciate  the 
modern  teachings  of  hygiene  and  sanitation.  One  of  the 
most  pernicious  results  of  dirt  is  dust.  Dust  is  irritating 
and  injurious.  Dusty  roads,  dusty  houses,  and  dusty 
workshops  mean  dirt  and  neglect.  Some  kinds  of  dust  are 
more  trying  than  others,  but  all  kinds  are  injurious. 

Fresh  air  and  sunshine  are  natural  aids  to  cleanliness. 
They  destroy  infection  and  purify  surfaces.  As  surface 
disinfectants,    fresh   air,    sunshine,    and    cleanliness   rate 

23 


higher  in  the  opinion  of  most  sanitarians  than  the  germi- 
cidal gases  used  to  fumigate  a  room. 

The  subject  of  cleanliness  cannot  be  left  without  a  word 
about  decency  as  applied  to  hygiene  and  sanitation.  The 
health  officer  is  no  longer  swayed  by  sentiment,  but  guided 
by  facts.  Nevertheless,  sentiment  cannot  be  disregarded  in 
sanitation  any  more  than  we  can  banish  music,  or  beauty  of 
form  and  action  from  the  heart  of  man.  The  sanitarian 
frowns  upon  many  things  which  he  knows  may  not  be  par- 
ticularly harmful.  If  dried  figs  contain  a  few  worms  they 
pass  muster,  but  if  they  contain  many  they  are  condemned 
for  decency's  sake;  the  other  day  our  State  Board  of  Health 
condemned  a  lot  of  foodstuffs  that  had  been  in  cold  storage 
over  a  year,  not  because  they  thought  the  food  particularly 
harmful,  but  an  unnecessary  practice  and  one  fraught  with 
potential  danger,  however  slight,  in  other  words,  contrary 
to  public  decency.  Much  meat  is  condemned  not  because 
particularly  harmful,  but  people  object  to  it  on  sentimental 
grounds.  When  prices  soar  higher  and  we  become  flesh 
hungry  as  some  European  nations  now  are,  .we  will  use 
many  food  animals  that  are  now  condemned.  We  now  no 
longer  think  it  decent  to  drink  water  containing  sewage, 
even  though  boiled.  Filtration  will  strain  out  the  infec- 
tion but  will  not  eliminate  the  dissolved  chemicals.  It  took 
mankind  a  long  time  to  awaken  to  the  fact  that  the  in- 
expressibly nasty  habit  of  drinking  water  polluted  with 
sewage  was  not  only  not  nice,  but  dangerous.  In  Italy  the 
signs  in  the  railroad  carriages  read,  **For  hygiene  and 
decency  do  not  spit. ' '    The  moral  is  obvious. 

It  would  be  impossible  for  the  present-day  sanitarian  to 
improve  upon  the  oft-quoted  sentence,  ''cleanliness  of  the 
person  is  the  threshold  to  cleanliness  of  the  soul,  and  hence 
the  door  to  righteousness.''  We  need  only  to  refer  to  the 
Levitical  laws  to  become  impressed  with  the  fact  that  the 
practical  value  of  cleanliness  is  not  a  new  thought.  Thus 
we  read  in  Deuteronomy  'Hhou  shalt  have  a  place  also 
without  the  camp  whither  thou  shalt  go  forth  abroad,  and 
thou  shalt  have  a  paddle  upon  thy  weapon  and  it  shall  be 
when  thou  shalt  ease  thyself  abroad  thou  shalt  dig  there- 

24 


with,  and  shalt  turn  back  and  cover  that  which  cometh  from 
thee. ' '  This  is  an  instinctive  act  among  animals,  and  may 
be  seen  daily  in  the  habits  of  the  domestic  cat.  Even  wild 
animals  take  the  greatest  pains  not  to  foul  their  nests,  yet 
how  different  it  often  is  with  men  in  a  civilized  state.  For- 
merly man  literally  lived  on  a  dung  heap.  If  the  above 
primitive  injunction  concerning  camp  sanitation  had  been 
followed  by  our  troops  in  the  Spanish-American  war  it 
would  have  saved  thousands  of  cases  of  sickness  and  deaths 
from  typhoid  fever.  The  statistics  show  that  about  one- 
third  of  our  entire  command  in  that  war  contracted  this 
filth  disease  and  largely  because  proper  precautions  were 
not  taken  concerning  the  disposal  of  excreta.  During  the 
recent  flare-up  in  Mexico  our  troops  were  concentrated  on 
the  border  near  San  Antonio  in  Texas.  This  command, 
known  as  the  Texas  Manoeuvre  Division,  consisted  of  about 
20,000  officers  and  men,  and  among  them  were  only  two 
cases  of  typhoid  fever.  This  was  in  part  due  to  the  fact 
that  practically  all  the  officers  and  men  were  vaccinated 
against  typhoid,  but  this  alone  by  no  means  explains  the 
freedom  from  the  disease,  for  in  addition  the  camp  was  a 
model  of  cleanliness  and  sanitation. 

Concerning  bacterial  vaccines,  a  warning  is  necessary. 
The  sanitarian  welcomes  every  specific  therapeutic  agent  as 
he  welcomes  anything  that  helps  check  the  prevalence  of  the 
communicable  diseases.  He  doubts,  however,  the  advisability 
of  artificially  raising  immunity  by  means  of  bacterial  vac- 
cines as  a  wise  measure  for  the  population  at  large.  Per- 
sons who  have  to  visit  a  city  during  a  typhoid  outbreak,  or 
physicians,  nurses  and  ward  tenders  in  the  typhoid  wards 
of  hospitals,  or  travelers  in  a  country  where  typhoid  is 
endemic,  or  soldiers  in  a  camp,  or  persons  unduly  exposed, 
should  protect  themselves  with  typhoid  vaccine.  The  im- 
munity thus  produced,  however,  does  not  permit  them  to 
heedlessly  disregard  the  rules  of  sanitation  and  hygiene. 
The  sanitarian  believes  that  it  would  be  much  better  to 
fight  typhoid  and  also  tuberculosis  along  the  lines  of  hy- 
giene and  sanitation,  even  though  it  may  take  a  long  time 
to  conquer  these  infections,  but  once  conquered  along  these 
lines  the  victory  will  be  enduring. 

25 


SANITARY  ISOLATION. 

Sanitary  isolation  is  an  impossibility.  Any  system  of 
quarantine  that  attempts  to  protect  with  a  Chinese  wall  is 
doomed  to  fail.  Massachusetts  might  today  free  itself  of 
measles  or  tuberculosis,  but  tomorrow  it  would  become  re- 
infected from  neighboring  states.  Infection  flows  from 
the  country  to  the  city,  therefore  no  city  is  safe  with  in- 
fected suburbs,  or  especially  with  infection  upon  the  drain- 
age basin  from  which  the  water  supply  is  obtained,  or  upon 
the  milk  drainage  area.  Germs  are  social  climbers  and  find 
their  way  into  the  palace  on  the  plaza  or  the  castle  on  the 
crags.  We  can  place  a  social  guard  at  our  front  door, 
but  there  is  no  sanitary  watchman  to  protect  the  back  door. 
A  typhoid  bacillus  does  not  ride  up  with  a  footman  and 
livery  and  announce  his  call  with  his  name  emblazoned  on  a 
visiting  card.  He  may  come  unannounced  into  the  best 
ordered  house  in  a  bottle  of  milk,  or  in  the  person  of  a 
housemaid  or  workman.  So  long  as  slums  are  permitted 
and  crowded  tenements  are  tolerated,  those  who  live  on  the 
boulevard  are  not  safe. 

Man's  protection  of  his  fellowmen  has,  therefore,  become 
a  matter  of  individual  concern.  It  is  not  only  a  question  of 
self-preservation,  but  the  health  and  happiness  of  those 
near  and  dear.  Man's  sanitary  duty  to  his  fellowmen  an- 
swers the  question,  **Am  I  my  brother's  keeper?"  For- 
merly each  individual  or  each  community  heedlessly  al- 
lowed its  sewage  to  run  into  the  stream,  without  a  thought 
of  those  who  drank  the  water  below.  Cities  upon  lakes 
emptied  their  sewage  into  the  lake  and  took  the  diluted 
sewage  at  another  point  close  by.  Today  a  man's  sanitary 
conscience  should  not  allow  him  to  defile  the  stream.  If 
his  sanitary  conscience  does  not  prick  him,  then  the  sanitary 
police  should  compel  him  to  have  a  due  regard  for  the 
rights  and  safety  of  others. 

The  discovery  of  carriers  has  increased  the  difficulty  of 
sanitary  isolation.  In  many  diseases  carriers  are  more 
numerous  than  the  cases.  Thus  from  2  to  4%  of  all  cases 
of  typhoid  fever  become  carriers.    In  cerebrospinal  fever 

26 


the  carriers  outnumber  the  cases  10  to  1.  It  is  believed 
that  the  missed  and  abortive  cases  of  infantile  paralysis  are 
much  more  numerous  than  the  paralytic  cases  so  easy  to 
recognize.  The  carrier  problem  has  greatly  complicated  the 
program  and  renders  the  process  of  eliminating  certain 
infections  complex  and  difficult. 

There  is,  however,  reason  to  believe  that  the  time  will 
soon  come  when  carriers  will  be  cured,  and,  better  still,  we 
know  that  many  of  them  can  be  prevented  by  early  recogni- 
tion of  the  case  and  intelligent  isolation  of  the  patient. 
Every  case  of  infectious  disease  known  is  a  case  neutralized, 
and  experience  teaches  that  the  number  of  carriers  dimin- 
ishes in  a  community  pari  passu  with  the  decrease  in  the 
number  of  clinical  cases.  Isolation  with  all  its  imperfec- 
tions and  disappointments  will  continue  to  remain  an  im- 
portant measure  to  check  the  spread  of  infection. 

Sanitary  engineering  works,  especially  those  involving 
disposal  of  sewage  and  wastes,  purification  of  water  or 
drainage  of  land,  require  a  large  outlay  of  money.  The  ex- 
penditure, however,  is  economical  in  the  light  of  the  bene- 
fits derived.  The  sanitarian  knows  no  greater  extravagance 
than  the  false  economy  in  matters  of  this  sort.  Communi- 
ties are  gradually  awakening  to  the  fact  that  these  things 
pay.  A  healthy  city  attracts  trade  and  travel,  and  people 
are  now  rightly  demanding  a  clean  bill  of  health  from  com- 
munities with  which  they  have  personal  commerce.  "Pub- 
lic health  is  purchasable ;  within  natural  limitations  a  com- 
munity can  determine  its  own  death-rate.''  It  seems 
strange  that  such  an  intangible  and  mysterious  quality  as 
health,  long  regarded  as  a  gift  of  God,  should  become  a 
commercial  article  to  be  bartered  in  our  legislature  halls. 

Legislators  often  do  not  heed  the  demands  of  the  few 
for  a  number  of  reasons.  Science  has  run  ahead  of  public 
health  administration  by  leaps  and  bounds,  so  that  there 
has  been  more  than  the  usual  lag  in  the  diffusion  of  the  new 
knowledge.  Again  it  is  difficult  for  legislators  to  winnow 
the  wheat  from  the  chaff  out  of  the  harvest  of  novelties,  half 
truths,  theories  and  speculations  that  fill  the  bams  of  the 
experimenters.    Furthermore,  science  deals  only  with  cold 

27 


facts  and  will  have  nothing  to  do  with  emotions,  intuitions, 
instinct  or  other  categories  that  philosophers  make  so  much 
of.  The  very  fact  that  science  limits  itself  strictly  to  facts 
that  may  be  measured  or  weighed  is  at  once  its  strength 
and  its  weakness.  Man  is  not  simply  made  up  of  a  material 
aggregation  of  matter,  and  therefore  the  discovery  of  a 
method  of  preventing  or  curing  disease  cannot  always  be 
applied  immediately.  There  are  many  complicating  factors 
between  the  discovery  of  a  new  fact  and  its  practical  appli- 
cation. For  example,  we  have  sufficient  information  to 
stamp  out  hookworm  disease,  malaria,  beriberi,  and  many 
other  afflictions,  but  they  continue  and  are  likely  to  con- 
tinue to  decimate  the  ranks  for  many  generations  to  come. 
When  Eonald  Ross  had  worked  out  the  life  history  of  the 
malarial  parasite  in  the  mosquito  he  broke  out  into  song : — 

"I  know  this  little  thing 
A  myriad  men  will  save. 
O  Death,  where  is  thy  sting, 
Thy  victory,  O  grave." 

But  although  we  know  the  cause  of  malaria,  its  mode  of 
transmission,  and  although  we  know  how  to  prevent  it,  and 
even  possess  a  cure,  the  disease  still  counts  its  victims  by 
the  hundreds  of  thousands  annually. 

Tuberculosis  offers  another  illustration  in  which  many 
complicating  factors  have  made  its  control  a  sociologic  and 
economic  rather  than  an  exclusively  medical  question.  "We 
can  preach  and  teach  all  we  want  about  the  importance  of 
fresh  air,  sunshine,  good  food,  rest  and  recreation,  but  until 
justice  takes  the  place  of  charity,  many  of  these  things  will 
remain  beyond  the  ability  of  most  men  to  purchase.  The 
rich  man  can  determine  his  hours  of  work  and  play,  can 
travel  in  quest  of  change  and  climate,  can  afford  nourishing 
food,  well  cooked,  and  can  readily  obtain  many  other  hy- 
gienic necessities  that  were  formerly  regarded  as  luxuries. 
The  poor  man  must  accept  conditions  much  as  he  finds 
them,  and  if  overwrought  and  underpaid  he  cannot  effec- 
tively guard  against  tuberculosis.  In  this  sense  the  rich 
man  can  purchase  health  and  life  itself,  and  in  this  sense 

28 


tuberculosis  and  also  infant  mortality  have  become  class 
diseases.  Science  has  pointed  the  way;  it  remains  for 
society  to  apply  the  remedy. 

It  has  been  made  plain  that  it  is  going  to  take  a  long 
time  to  greatly  diminish  the  prevalence  of  tuberculosis  and 
other  infections.  Patience,  therefore,  is  one  of  the  virtues 
that  the  health  officer  must  possess  and  teach. 

TR.AINED  LEADERSHIP. 

Health  administration  in  this  country  lags  largely  for 
want  of  trained  leadership.  The  call  to  public  health  is 
loud  and  clear.  Preventive  medicine  is  the  watchword  of 
the  hour,  and  the  people  are  asking,  '  *  If  disease  is  prevent- 
able, why  is  it  not  prevented  ? "  They  are  not  satisfied  with 
promises,  but  demand  results ;  this  is  as  it  should  be.  It  is 
now  recognized  that  the  orthodox  training  leading  to  the 
degree  of  M.D.  does  not  necessarily  fit  a  man  for  the  posi- 
tion of  health  officer.  The  average  practitioner  learns  little 
concerning  vital  statistics,  sanitary  engineering,  water  puri- 
fication, sewage  disposal,  disinfection,  forensic  medicine, 
and  the  making  and  breaking  of  health  laws.  The  public 
health  officer  looks  upon  disease  in  the  large,  and  is  less 
interested  in  the  individual  case,  which  is  the  chief  concern 
of  the  practicing  physician.  The  health  officer  looks  upon 
disease  with  an  eye  to  preventing  its  spread — in  order  to 
do  so  he  must  know  its  mode  of  transmission.  The  prac- 
ticing physician,  on  the  other  hand,  looks  upon  disease 
with  a  view  to  affording  relief  or  cure,  and  his  principal 
interest,  therefore,  is  in  diagnosis  and  treatment.  The  pub- 
lic health  officer  must  also  be  a  specialist.  Public  health 
administration  is,  indeed,  a  profession  which  bends  its  knee 
to  none,  so  far  as  ideals  and  service  are  concerned. 

The  administration  of  public  health  matters  has  some- 
times failed  or  has  been  in  large  degree  unprofitable  by 
reason  of  being  out  of  balance  with  other  problems  that 
press  in  upon  the  community  life.  Technical  features  are 
sometimes  allowed  to  overshadow  or  obscure  the  essential 
humanitarian  motives.  A  well-developed  sense  of  values, 
and  the  right  kind  of  attitude  toward  the  common  welfare 

29 


are  quite  as  essential  in  the  equipment  of  a  health  officer  as 
technical  knowledge  and  ability. 

It  must  not  be  understood  that  the  health  officer  is  con- 
cerned only  with  stamping  out  the  communicable  diseases. 
There  are  many  preventable  defects  which  may  be  reached, 
especially  in  school  children,  and  there  is  the  general  con- 
duct of  life  which  makes  not  only  for  longevity  but  for 
maximum  efficiency.  The  present-day  health  officer  must 
also  concern  himself  with  the  problems  of  heredity  and 
eugenics.  He  must  further  concern  himself  with  questions 
of  immunity,  and  must  make  every  effort  to  help  the  con- 
ditions which  menace  work-people.  Industrial  hygiene  and 
the  diseases  of  occupation  form  a  large  and  important  chap- 
ter in  the  volume  of  preventive  medicine.  Furthermore,  the 
people  must  depend  upon  the  health  officer  to  guard  the 
quality  of  the  food,  including  the  purity  of  the  milk,  and 
the  cleanliness  of  the  water  which  they  consume.  The 
health  officer  must,  therefore,  be  familiar  with  the  sanitary 
sciences  in  addition  to  the  medical  sciences,  both  of  which, 
in  the  broad  biological  sense,  underlie  the  foundation  of 
successful  health  administration. 

In  order  to  meet  this  demand  for  trained  leadership. 
Harvard  University  and  the  Massachusetts  Institute  of 
Technology  have  established  a  School  for  Health  Officers. 
Other  universities,  notably  Pennsylvania,  Wisconsin,  and 
Michigan  have  likewise  established  courses  to  train  men  to 
officer  the  public  health  army. 

Politics  have  been  the  curse  of  health  administration  in 
this  country.  Politics  and  sanitation  do  not  mix.  It  is 
important  to  divorce  the  two.  Only  those  should  be  ap- 
pointed to  the  position  of  health  officer  whose  training  ade- 
quately prepares  them  for  the  work.  Such  persons  should 
be  given  compensation  commensurate  with  their  great  re- 
sponsibility, and  the  tenure  of  office  and  other  conditions 
should  be  attractive  so  as  to  induce  competent  men  to  enter 
and  build  up  the  profession. 

It  is  pleasurable  enough  to  recount  the  progress  of  the 
sanitary  sciences,  but  amid  all  the  great  achievements  we 
are  not  blind  to  the  fact  that  many  problems  remain  un- 

30 


I 


I 


solved.  Cancer  and  pneumonia  still  defy  us — for  how  long 
who  can.  say  ? — for  many  workers  in  many  workshops  are 
attacking  these  and  other  pathological  puzzles  with  unre- 
mitting zeal.  That  they  will  be  solved,  and  solved  by  the 
experimental  method,  is  the  firm  conviction  of  those  who 
are  on  the  firing  line. 

The  power  we  now  possess  to  diminish  or  even  conquer 
some  of  the  communicable  diseases  has  entirely  over- 
shadowed the  importance  of  the  non-communicable  affec- 
tions. It  is  quite  as  important  to  guard  against  organic 
disease  of  the  heart,  kidney,  liver  or  brain  as  it  is  to  guard 
against  typhoid  fever,  tuberculosis,  or  smallpox.  Further- 
more, the  object  of  preventive  medicine  is  not  alone  to 
prevent  infection  or  the  premature  occurrence  of  the  de- 
generations which  inevitably  come  with  advancing  years, 
but  seeks  to  give  each  individual  the  maximum  daily  effi- 
ciency during  his  allotted  lifetime.  It  is  perhaps  even 
more  important  to  live  efficiently  than  to  live  long.  He 
who  does  nothing  all  his  days  but  care  for  his  body  so  as 
to  prolong  his  life  may  neglect  many  material  obligations 
and  moral  responsibilities.  Therefore  euthenics  has  be- 
come an  integral  part  of  the  program  of  preventive  medi- 
cine. In  brief,  the  object  of  preventive  medicine  is  not 
alone  to  live  longer,  for  it  serves  little  purpose  to  live 
longer  if,  at  the  same  time,  we  cannot  live  healthier,  hap- 
pier and  better  lives. 

In  reviewing  the  successes  of  science  we  are  not  blinded 
by  the  glare  of  its  glories.  The  progress  has  been  satisfy- 
ing, even  brilliant,  but  only  the  surface  has  been  scratched ; 
our  ignorance  of  life  and  its  laws  remains  abysmal.  A 
clear  knowledge  of  what  we  do  not  know  is  quite  as  im- 
portant as  a  knowledge  of  what  we  do  know.  Formerly  it 
took  a  bold  man  to  peep  into  the  darkness;  now  many  a 
Columbus  sails  the  unchartered  seas  with  undaunted  spirit, 
hoping  to  find  a  new  continent,  even  though  only  searching 
a  new  route. 

The  limitations  of  the  human  mind,  as  well  as  the  de- 
linquencies and  defects  of  the  human  body,  are  brakes 
upon  the  wheels  of  progress. 

31 


The  student  of  preventive  medicine  frankly  faces  the 
fact  that  the  mass  of  mankind  is  diseased,  ignorant,  and 
unmoral.  He  has  dedicated  himself  to  the  task  of  helping 
to  cleanse,  teach,  and  regenerate. 

Preventive  medicine  dreams  of  a  time  when  there  shall 
be  enough  for  all,  and  every  man  shall  bear  his  share  of 
labor  in  accordance  with  his  ability,  and  every  man  shall 
possess  sufficient  for  the  needs  of  his  body  and  the  demands 
of  health.*  These  things  he  shall  have  as  a  matter  of 
justice  and  not  of  charity.  Preventive  medicine  dreams  of 
a  time  when  there  shall  be  no  unnecessary  suffering  and 
no  premature  deaths ;  when  the  welfare  of  the  people  shall 
be  our  highest  concern;  when  humanity  and  mercy  shall 
replace  greed  and  selfishness ;  and  it  dreams  that  all  these 
things  will  be  accomplished  through  the  wisdom  of  man. 
Preventive  medicine  dreams  of  these  things,  not  with  the 
hope  that  we,  individually,  may  participate  in  them,  but 
with  the  joy  that  we  may  aid  in  their  coming  to  those  who 
shall  live  after  us.  When  young  men  have  visions  the 
dreams  of  old  men  come  true. 


*  These  concluding  sentences  are  paraphrased  from  Victor  C.  Vaughan's  admir- 
able address  on  the  'Thiloeophy  of  a  Scientist,"  Science,  Aug.  23,  1912,  N.  S. 
Vol.  xxxvi,  No  921,  p.  225. 


32 


GENERAL  LIBRARY 
UNIVERSITY  OF  CALIFORNIA— BERKELEY 

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